It's Roll-Up-Your-Sleeves Time

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After 21 months of campaigning, incessant coast-to-coast travel, and seemingly countless promises made, our President-Elect and House and Senate representatives have finally been identified. Whether or not your candidates will be sitting in new or existing seats, there is no question that the true challenge when it comes to health care reform now lies ahead.

The presidential campaign was marked by the unrelenting demand for health care reform, an issue that has been on many candidates’ platforms for years, yet still goes unresolved. Some skeptics have posited that health care reform is an unreachable goal. Others insist that any change will be met with resistance because the costs (both financial and nonmonetary) are beyond what the United States can or is willing to afford.

Of course, there are two fundamental views on health care reform—and to some degree they are distinctly different with regard to the changes that need to be implemented and also the when and how of putting those changes into effect. There are key differences on what are seen as the primary goals of health care reform. Do we reach for universal or near-universal health insurance coverage? Or something less ambitious?

There are also divergent opinions as to the purpose of health insurance. Is it to provide comprehensive insurance that encourages preventive care and protects the consumer from the financial burdens of an illness? Or is it to provide a plan with significant deductibles but with protection against catastrophic illness, allowing for saving accounts and pretax dollars to pay for routine health care? The supporters of the latter option submit that such a plan makes people better consumers of health care. But regardless of the payment structure, it is imperative to remember that the core problems in the health care conundrum are economic in nature, and the ultimate challenge is making sure that everyone has access to affordable care.

Still, in the midst of all the debates about cost and coverage, the issues of provider shortages, reimbursements, and scope of practice in many ways took a back seat during this election year. When the issue of access is addressed, it is usually only with regard to affordable health care.

Throughout all of the discussions about reform, one key solution—increased recognition of the importance of NP and PA practice—has yet to be mentioned. Despite being significant providers, in numbers and in experience, in the health care arena, NPs and PAs still wear a virtual cloak of invisibility. In many instances, we are overlooked when national data are collected on patient visits, laboratory tests ordered, and number of prescriptions written.

One might ask, “Why does this matter?” Quite simply, the data confirm our contributions to the health care system in the US and offer proof that our professions are necessary to meet the needs of primary and specialty care in the future. Being invisible means that we are not considered a part of the solution to the shortage of primary care providers, that we are not part of the solution to people having access to care in their home communities.

Health policy researchers have suggested that stakeholders look to recent changes in Massachusetts geared toward relieving the burden of broader access in the aftermath of mandatory insurance enacted in 2007. This year, the Massachusetts legislature allowed for the recognition of NPs as primary care providers (Chapter 305 of the Acts of 2008), which resulted in an instant and significant increase in the number of providers available to residents of the Commonwealth. Just as the need for more providers in Massachusetts became apparent and NPs proved to be the answer, it is imperative that any national reform includes allowing professionals who have met the requisite licensing and qualifications standards to fully function in their roles as health care providers.

However, our health care system is still inextricably tied to the physician model in ways that often hinder our ability to reach out to those who are disenfranchised from the system or to provide expanded access to care. Don’t misunderstand, there is a need for our physician colleagues—and we will always turn to them for assistance in problem solving on a difficult case (in the same way they consult with each other and with us). However, in many states, the requirement that NPs and PAs must have charts cosigned by a physician, or that there must be a certain ratio of NPs or PAs to MDs in a practice, constrains our ability to function as responsible, educated, autonomous providers. I submit that it is these restrictions and oversight requirements that contribute to skyrocketing health care costs and impede access to care.


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